Formulary guidance and transparency from P&T to point of care

Trends That Matter for COPD Medications

Posted by Jane Anderson on Jun 20, 2019

A new generic alternative for GlaxoSmithKline's Advair Diskus (fluticasone/salmeterol) provides payers with the chance to better manage care in chronic obstructive pulmonary disease (COPD), a condition in which high out-of-pocket costs often lead to lower compliance and an increased risk of hospitalization, AIS Health reported.

Advair Diskus, a combination long-acting beta-agonist and an inhaled corticosteroid, has been one of the most common drugs used for COPD, a condition largely dominated by brand products. The generic, marketed by Mylan and approved Jan. 30, joins generics for two additional COPD devices: a generic for Ventolin HFA (albuterol) and one for Proair HFA (albuterol).
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Topics: Industry Trends, Data & Analytics

Radar On Market Access: Magellan Rx Initiates Oncology Biosimilars Program

Posted by Judy Packer Tursman on Jun 20, 2019

Magellan Rx Management, the PBM division of Magellan Health, Inc., on June 4 announced its launch of an oncology biosimilars program, preparing its health plan customers for the expected market entry of biosimilars for three cancer-fighting drugs — Herceptin, Rituxan and Avastin — later this year, AIS Health reported.

"Oncology is by far the largest therapeutic area for drug spend on the medical benefit, and it is even higher in Medicare," Steve Cutts, senior vice president and general manager for Magellan Rx's specialty drug unit, tells AIS Health. Thus, he says, the PBM will be focusing the oncology biosimilars program "on all lines of business for our clients."
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Topics: Specialty, Industry Trends, Market Access

Radar On Market Access: Payers Are Wary as First NASH Drugs May Hit U.S. Market Soon

Posted by Judy Packer Tursman on Jun 18, 2019

Doctors trying to treat patients with nonalcoholic steatohepatitis (NASH) — a serious type of nonalcoholic fatty liver disease (NAFLD) that, if left untreated, may progress to cardiovascular disease, cirrhosis, cancer and possibly the need for a liver transplant — soon may have new options in their arsenal beyond promoting exercise and diet. The first-ever NASH drugs are expected to hit the U.S. market as early as 2020 to help address this increasingly prevalent, complex disease spawned largely by the obesity epidemic and surge of type 2 diabetes in the U.S., AIS Health reported.

Dieterich says the entry of first-ever NASH medications will "definitely" offer significant benefit to patients. "There's no question [the drugs will help] — in combination with diet and exercise," says Douglas Dieterich, M.D., director of the Institute for Liver Medicine at Mount Sinai Health System. "It will have to be the whole package."
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Topics: Specialty, Industry Trends, Market Access, Product Release, Provider, Payer

Perspectives on CMS's Drug Pricing Proposals

Posted by Judy Packer Tursman on Jun 13, 2019

When CMS issued the final rule on Medicare Advantage and Part D drug pricing on May 16, the agency touted its policy changes as ensuring consumers get greater transparency into the cost of Part D prescription drugs and enabling MA plans to negotiate better prices for physician-administered medicines in Part C. Yet, after receiving 4,000-plus comments related to pharmacy price concessions on negotiated price, CMS held back, saying it won't implement this policy for 2020 — or follow through on proposed exceptions to Part D protected drug classes, AIS Health reported.

Among numerous provisions, CMS's final rule implements the statutory prohibition against gag clauses in pharmacy contracts, barring Part D plans from penalizing pharmacies that disclose a lower cash price to enrollees. But the agency decided against implementing a policy redefining negotiated price as the lowest possible, baseline payment to pharmacies.
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Topics: Industry Trends, Data & Analytics, Provider, Payer

Radar On Market Access: Outstanding Part D Proposals Created Uncertainty in 2020 Bid Process

Posted by Lauren Flynn Kelly on Jun 13, 2019

Medicare Advantage and Part D plan sponsors submitting bids for the 2020 plan year faced a considerable amount of uncertainty compared with recent years. On the Part D side, there was "not only one but two pending regulations — both of which would have had a significant impact on bids — and it was difficult for carriers to know 1) how they should bid and 2) how others might be bidding," Shelly Brandel, a principal and consulting actuary in the Milwaukee office of Milliman, tells AIS Health.

Perhaps creating the most uncertainty was when HHS would finalize a January proposed rule that would eliminate safe-harbor protections for rebates paid by manufacturers to plan sponsors under Medicare Part D and Medicaid. CMS in Part D bidding guidance posted May 20 confirmed what it had hinted at in an April memo on how bids should be prepared: the rule would not be finalized before the June 3 bid deadline.
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Topics: Industry Trends, Provider, Payer

Radar On Market Access: Payers Will Likely Use Various Tactics to Manage Zolgensma

Posted by Angela Maas on Jun 11, 2019

With the first therapy north of $1 million gaining FDA approval last month, payers likely will implement a variety of strategies to manage Zolgensma (onasemnogene abeparvovec-xioi), a one-time gene therapy from AveXis, Inc., a Novartis company. For now, many uncertainties exist with respect to the new treatment and what its place will be in spinal muscular atrophy (SMA) care, AIS Health reported.

According to Lee Newcomer, M.D., principal at Lee N. Newcomer Consulting LLC, payers likely will implement "strict enforcement of the label restrictions, advisory panels to develop clinical criteria for therapy [and] highly specific provider networks to ensure that the therapies are given correctly."
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Topics: Specialty, Industry Trends, Market Access, Product Release, Provider, Payer

Trends That Matter for Use of Biologics

Posted by Angela Maas on Jun 6, 2019

Almost 5.8 billion prescriptions were dispensed in the United States in 2018, an increase of 2.7% over the previous year, according to the IQVIA Institute for Human Data Science’s report Medicine Use and Spending in the U.S.: A Review of 2018 and Outlook to 2023, AIS Health reported.

Retail and mail pharmacies dispensed 127 million specialty prescriptions last year, an increase of 15 million since 2014. In 2018, for the second year in a row, specialty prescription volume grew more than 5% although the medicines accounted for only 2.2% of prescriptions overall. With an increase in the availability of oral and self-injected specialty therapies, these drugs "are increasingly dispensed through retail pharmacies," said Murray Aitken, executive director of the institute, during a May 6 press call.
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Topics: Industry Trends, Data & Analytics

Radar On Market Access: Oncology Is Experiencing Surge Of Innovation — and Prices

Posted by Angela Maas on Jun 6, 2019

The oncology space continued its trend of developing innovative therapies — both those launching and in the pipeline — in 2018. That's according to a new report from the IQVIA Institute for Human Data Science titled Global Oncology Trends 2019: Therapeutics, Clinical Development and Health System Implications. And while the outlook continues to look promising in terms of the science, it may pose issues to the health care system that need to be resolved in order to take full advantage of next-generation oncology products, AIS Health reported.

The 15 new oncology drugs and one supportive care drug launched last year for 17 tumor types marked a record. "Importantly, one of the new drugs is tissue-agnostic" — Loxo Oncology, Inc. and Bayer Corp.'s Vitrakvi (larotrectinib) — noted Murray Aitken, executive director of the institute, during a May 23 media call to discuss the report’s findings. "Over half of the new drugs are oral therapies, continuing this trend toward more of the targeted, innovative therapies being available in an oral form. Two-thirds of the new drugs have an orphan indication, continuing this trend towards cancer being redefined into narrower segments."
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Topics: Industry Trends, Market Access, Data & Analytics

Radar On Market Access: Blues Plans Promote Alternative Treatments to Combat Opioid Epidemic

Posted by Jane Anderson on Jun 4, 2019

Blues plans are promoting alternatives to opioids — and are seeing some increased uptake of alternatives such as acupuncture — but are hampered by employer policies that either don’t cover or place limits on many of those alternatives. Still, employers are showing interest in providing alternatives to opioids, plans say, and individual Blues plans are taking steps to update their coverage and encourage physicians to prescribe non-opioid chronic pain treatments, AIS Health reported.

Caesar DeLeo, M.D., executive medical director at Highmark Health, tells AIS Health that Highmark promotes Centers for Disease Control and Prevention guidelines for chronic pain management, which stress non-opioid treatments.
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Topics: Industry Trends, Payer

Radar On Market Access: Express Scripts Takes on Industry's Digital Transformation

Posted by Judy Packer Tursman on May 30, 2019

Cigna Corp.'s Express Script PBM expects to introduce the industry's first stand-alone "digital health formulary" in 2020, the company said May 16. It intends to use a uniform review process to ensure the safety and quality of apps and devices on the market for diabetes, cardiovascular and pulmonary conditions and behavioral health, AIS Health reported.

By creating a digital formulary, Express Scripts "is using old hat methods to manage these new digital health solutions much like they do on brand and generic drugs or other therapies via utilization management," says Nathan Ray, senior principal in business consulting firm West Monroe Partners’ health care and life sciences practice.
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Topics: Industry Trends, Data & Analytics, Provider, Payer